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What GAO Found

The Veterans Millennium Health Care and Benefits Act (Millennium Act) authorizes the Department of Veterans Affairs (VA) to cover emergency care for conditions not related to veterans' service-connected disabilities when veterans who have no other health plan coverage receive care at non-VA providers. However, GAO identified a number of instances where VA staff who processed claims did not comply with applicable requirements of the Millennium Act, its implementing regulations, or VA policies when they denied the claims. Specifically, at the four VA facilities included in this review, GAO found 66 instances of noncompliance among the 128 denied claims reviewed, which led some claims to be inappropriately denied. VA facilities subsequently reconsidered and paid 25 of these claims. GAO also found that VA facilities may not be notifying veterans as required that their Millennium Act claims have been denied. Eighty-three claims out of 128 that GAO reviewed lacked documentation that the veteran was notified of the denial or of his or her appeal rights. These findings suggest that veterans whose claims have been inappropriately denied may have been held financially liable for emergency care that VA should have covered, and they may not be aware of their rights to appeal these denials.

GAO also found that, as a result of weaknesses in VA's oversight of Millennium Act claims, VA facilities are at risk for inappropriately denying such claims. For example, agency oversight activities do not focus on compliance with all applicable requirements but rather on the timeliness of claims processing. In addition, VA has limited assurance that deficiencies relating to Millennium Act claims processing identified during reviews are corrected because it only conducts limited follow-up with VA facilities. Moreover, VA does not collect adequate data for monitoring the appropriateness of Millennium Act claim denials. This lack of data hinders VA's ability to track patterns as to why Millennium Act claims are denied and identify areas where communications with veterans and non-VA providers about Millennium Act emergency care benefits could be improved.

VA has used various methods to educate veterans about their Millennium Act eligibility; however, VA officials, non-VA providers, and representatives of veterans service organizations told GAO that veterans still lack knowledge about their eligibility. For example, VA officials reported that because some veterans were uninformed about their eligibility, these veterans may have delayed or avoided seeking treatment at local non-VA providers, choosing instead to go to a less accessible VA facility. Because VA does not require facilities to conduct evaluations of veterans' understanding of Millennium Act eligibility, it lacks information needed to address potential gaps in veterans' knowledge about these benefits. Also, the non-VA providers GAO interviewed cited communication challenges with VA regarding Millennium Act claims, such as not having a specific point of contact at VA for directing specific questions and raising concerns, and a lack of VA responsiveness when issues are raised. Despite VA's efforts to improve communications with non-VA providers after a 2011 customer service survey revealed significant issues, these challenges persisted at the facilities GAO visited.

Why GAO Did This Study

VA spent an estimated $418 million on Millennium Act emergency care claims in fiscal year 2012 and projects spending will increase to $580 million by fiscal year 2015. GAO was asked to review VA's administration of the emergency care benefit under the act. This report examines the extent to which (1) selected VA facilities complied with applicable requirements, in particular when denying claims; (2) VA's oversight activities ensure that Millennium Act claims are not inappropriately denied; and (3) veterans understand the Act's emergency care benefit and how VA communicates with non-VA providers about Millennium Act claims.

To do this work, GAO reviewed 4 VA facilities out of 142 based on variations in Millennium Act spending levels and geographic location. GAO also reviewed VA documents—including 128 denied Millennium Act claims from these four facilities—and interviewed officials from VA, non-VA providers, and veterans service organizations. These results cannot be generalized across VA but provide insights.

What GAO Recommends

GAO recommends that VA take a number of actions, including steps to ensure facilities comply with applicable requirements, notify veterans of denials, improve oversight of claims processing, and collect better data on denials and veterans' understanding of eligibility for Millennium Act coverage. VA agreed with the recommendations and described its plans to implement them. However, as described in the report, GAO believes that some of VA's proposed actions do not fully address the issues identified.

Recommendations for Executive Action

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to implement measures to ensure that all VA facilities comply with VA's policy requirement that incoming claims be date-stamped and scanned into FBCS on the date of receipt.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to clarify policies and guidance for processing Millennium Act claims to specify that clinicians determine whether emergent care is related to a veteran's service-connected disability before other Millennium Act criteria are applied to claims, and implement measures to ensure that all VA facilities comply with this policy.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to clarify the policy for processing Millennium Act claims to communicate the importance of promptly verifying that claims have been sent to the correct VA facility, and implement measures to ensure that all VA facilities comply with this policy.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to revise VA policy for processing Millennium Act claims to require that VA fee basis staff who process the claims use the VSSC Find User search to make determinations about veterans' enrollment and use of VA services.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To address VA facilities' compliance with applicable requirements for processing non-VA provider emergency care claims, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a VA policy regarding processing Millennium Act claims to require VA facilities to assist the veteran in determining whether a claim is eligible for coverage by auto insurance or another third party before denying the claim; and ensure that the standard letters sent to veterans whose claims are denied because of third-party liability, in this case auto insurance coverage, more clearly communicate that the denial could be overturned if the veteran can prove that auto insurance did not fully cover the claim.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To better ensure that veterans are notified of Millennium Act emergency care claim denials, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require fee basis supervisors at each VA facility to develop mechanisms for verifying that veteran denial letters are printed and mailed.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To improve oversight of Millennium Act claims processing by increasing the focus on determining whether claims are inappropriately denied and ensuring that deficiencies are corrected, the Secretary of Veterans Affairs should direct the Under Secretary for Health to revise the scope of field assistance visits to include an assessment of whether fee basis staff are making appropriate decisions about whether Millennium Act claims meet administrative and clinical criteria for payment.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To improve oversight of Millennium Act claims processing by increasing the focus on determining whether claims are inappropriately denied and ensuring that deficiencies are corrected, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require VA facilities to systematically audit the appropriateness of Millennium Act claim approvals and denials by taking actions such as revising VA Central Office's internal controls procedure guide for fee basis managers or by establishing performance measures related to the appropriateness of claim approval or denial decisions for fee basis staff.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To improve oversight of Millennium Act claims processing by increasing the focus on determining whether claims are inappropriately denied and ensuring that deficiencies are corrected, the Secretary of Veterans Affairs should direct the Under Secretary for Health to require VA facilities to correct fee basis claims processing deficiencies that are identified through field assistance visits or virtual audits, once they are implemented, and establish a process for validating facilities' self-reported actions taken to address deficiencies.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To improve VA's ability to identify systemwide patterns in denials, areas of noncompliance in VA facilities' processing of Millennium Act claims, and areas where communications for veterans and non-VA providers could be improved, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a standard set of Millennium Act denial reasons in FBCS that are specific and aligned with the Millennium Act administrative and clinical criteria, and ensure they are consistently applied across VA facilities.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To improve VA's ability to identify systemwide patterns in denials, areas of noncompliance in VA facilities' processing of Millennium Act claims, and areas where communications for veterans and non-VA providers could be improved, the Secretary of Veterans Affairs should direct the Under Secretary for Health to establish a regular reporting mechanism through which VA facilities would provide to VA Central Office data related to the appropriateness of decisions to approve or deny Millennium Act claims.

Agency Affected: Department of Veterans Affairs

Status: Open

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Recommendation: To improve VA's ability to address its strategic plan objective of educating and empowering veterans, the Secretary of Veterans Affairs should direct the Under Secretary for Health to take steps to better understand gaps in veterans' knowledge regarding eligibility for Millennium Act emergency care, such as by conducting veteran surveys of health care benefits knowledge, and using information from those surveys to more effectively tailor the agency's education efforts regarding the Millennium Act benefit. In conducting these surveys, consideration should be given to including a sample of veterans who have had denied Millennium Act claims in order to provide their views and specific details of their experiences.